Schedule D (Form 941) - IRS

[Pages:2]Schedule D (Form 941):

Report of Discrepancies Caused by Acquisitions, Statutory Mergers, or Consolidations

(Rev. June 2011) Department of the Treasury--Internal Revenue Service

OMB No. 1545-0029

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Employer Identification Number (EIN)

Tax Year of Discrepancies (Fill in)

Name (not your trade name)

Format: YYYY

Trade name (if any)

Address

Number

City Phone number

Street

Suite or room number

State

ZIP code

Type of Submission (Check one) Original Corrected

About this schedule

Each year the Internal Revenue Service (IRS) and the Social Security Administration (SSA) compare the totals on your Forms 941, Employer's QUARTERLY Federal Tax Return, with the totals on Forms W-2, Wage and Tax Statement, to verify that:

? The wages you reported on Forms 941 match those you reported on Forms W-2 (Copy A) so that your employees' social security earnings records are complete for benefit purposes; and

? You have paid the appropriate taxes. Generally, the totals on your Forms W-2 (Copy A) should equal the totals you reported on Forms 941. Use this schedule if discrepancies exist between the totals you reported on those forms ONLY as a result of an acquisition, statutory merger, or consolidation. In many cases, the information on this schedule should help the IRS resolve discrepancies without contacting you. If you are an eligible employer who elects to use the alternate procedure set forth in Rev. Proc. 2004-53, explained in the instructions, you should file this schedule.

Read the separate instructions before you fill out this schedule.

Part 1: Answer these background questions.

1. Are you filing this schedule --

After a statutory merger or consolidation? (See Rev. Rul. 62-60, 1962-1 C.B. 186 and Rev. Proc. 2004-53, 2004-2 C.B. 320.) You are either: An acquired corporation or

OR

A surviving corporation.

After an acquisition and you are using the alternate procedure under Rev. Proc. 2004-53, 2004-2 C.B. 320? You are either: A predecessor or

A successor.

2. The effective date of the statutory merger/consolidation or acquisition is . . . . . . . . .

3. The OTHER PARTY in this transaction is . . .

Other party's EIN

--

MM / DD / YYYY

Other party's name

Trade name (if any)

Address

Number

Street

Suite or room number

City

Phone number

For Paperwork Reduction Act Notice, see separate instructions.

State Cat. No. 38791Y

ZIP code

Next Schedule D (Form 941) (Rev. 6-2011)

Your EIN

--

Name (not your trade name)

Other party's EIN

--

Tax Year of Discrepancies (Fill in) Format: YYYY

Part 2: Tell us about the discrepancies with your returns.

Column A

Column B

Column C

Amount you reported to IRS for the tax year

? Amount you reported to SSA for the tax year

= The difference

Totals from Forms 941 as corrected Totals from Forms W-2 (Copy A) as

by any Forms 941-X

corrected by any Forms W-2c (Copy A)

4. Social security wages

?

=

5. Medicare wages and tips

?

=

6. Social security tips

?

=

7. Federal income tax withheld

?

=

8. Advance earned income credit (EIC) payments (for tax years

?

=

ending before January 1, 2011)

If you are filing for one transaction only, STOP here. If you are filing for more than one transaction, go to Part 3.

Part 3: Fill this part out ONLY if you are filing more than one Schedule D (Form 941) for any calendar year.

9. File one Schedule D (Form 941) for each separate transaction. This is schedule

of

. (Example: This is schedule 1 of 3.)

Column A

Amount you reported to IRS for the tax year for the employees affected by the transaction reported on this Schedule D (Form 941)

Column B

? Amount you reported to SSA for the tax year for the employees affected by the transaction reported on this Schedule D (Form 941)

Column C = The difference

Totals from Forms 941 as corrected Totals from Forms W-2 (Copy A) as

by any Forms 941-X

corrected by any Forms W-2c (Copy A)

10. Social security wages

?

11. Medicare wages and tips

?

12. Social security tips

?

13. Federal income tax withheld

?

14. Advance earned income credit (EIC) payments (for tax years

?

ending before January 1, 2011)

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Schedule D (Form 941) (Rev. 6-2011)

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